NBS Dried Bloodspot Destruction Request

Request for Destruction of Newborn Dried Bloodspot Specimen
I request the Vermont Newborn Screening Program and screening laboratory destroy my child’s dried bloodspot specimen once all newborn screening tests are complete and the results have been released. I understand that dried bloodspots are generally only retained for one year, and that by destroying it earlier, it will no longer be available for additional testing. If the baby has more than one specimen those will also be destroyed.
Patient Identification
Date of Birth.

MonthDayYear
Date
If multiple birth, birth order (twin #1, #2, etc.
Birth Number
Name.

First NameLast Name
Sex.
Hospital or Location of Birth.
Name of birth place.
Hospital of Transfer (if applicable).
Hospital name.
Parent.

First NameLast Name
Any additional names by which the baby or parent may have been known at the time of collection:
Other name.
Documentation of Parent/Guardian Request
Signature of legal guardian (parent or other).
Printed name of legal guardian.

First NameLast Name
Date.

MonthDayYear
Date
Signature of additional legal guardian (parent or other).
Printed name of additional legal guardian.

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

Request for Destruction of Newborn Dried Bloodspot Specimen